Chapter 10

Man, 65 years old, heavy smoker, cough , dyspnea and weight loss.

AFB negative in sputum. Is TB possible?

The opacity of the left upper lobe is not cavited and looks like a tissular

mass, not alveolar picture, because of sharp limit and dense and

homogenous aspect . There is a silhouette sign with aortic arch: mediastinal

extension or adenopathies. The diagnosis of TB is improbable because no

cavity in the opacity . It is a bronchial cancer with mediastinal adenopathies

or mediastinal extension

Scan view of the previous case

2002: Young woman coming from Guinea, PLHIV (HIV2), cough and worsening condition

AFB positive in sputum: Right superior lobe tuberculous pneumonia. Small left superior

lobe infiltrate.

2002 2004

2009

Radiological evolution

after TB treatment :

retraction and fibrosis

June 2011: worsening condition and severe dyspnea. Producting cough:

positive AFB

TB Recurence. 2 hypothesis:

• 1° endogen reinfection in case of incorrect or non complete treatment: in this

case MDR TB must be suspected

• 2°Exogen reinfection: in this case probably no resistance to classical

treatment.

Specific PCR for research or resistance to anti TB drugs must be performed as

soon as possible to decid adequat treatment. (geneXpert)

Scan view

of the

previous

case

Woman, 82 years old, non productive cough and chronic severe dyspnea.Smear

negative for AFB. Past history of lung disease but no more information.

Typical aspect of bilateral calcified pleural sequella, from old TB. Notice the

« fishbone » aspect on the left side. No need of retreatment

Scan view of the previous case. Calcification of the left pleural wall .

Man, 80 years old, heavy smoker, right scapular pain and worsening condition

CXR: Right thoracic opacity with destruction of posterior arch of the 3rd 4th and 5th rib.

This opacity is not a lung opacity neither pleural one : it is a parietal opacity: probable

parietal extension of a bronchial cancer. In this case the diagnostic of TB is highly

improbable: no cavity in this bulky opacity , rib destruction.. Notice 2 others round

opacities in the inferior lobe suggesting metastasis.

Man, 58 years old non producting cough. Past history of pleural TB with

monthes TB treatment. Crepitant rales on the right side at auscutation. No

fever, chronic exercice dyspnea.

Non systematised opacity of the right inferior field with flatness of the

diaphragm. Pleural sequella,, consequence of pleural effusion past history..

This picture is difiicult to distinguish from pneumonia. Lateral view his helpfull

Acute dyspnea non purulent sputum and no fever. Auscultation: bilateral crepitant rales.

Chest X ray: antero- posterior incidence. Bilateral alveolar pictures (notice he aeric

bronchogram onthe left side). Clinical and radiological findings strongly suggest

pulmonary cardiogenic oedema, even if the alveolar pictures are not symetric.

Woman, 54 years old, cough and anterior thoracic paint.

Left hilar opacity, with overlap sign . This opacity is anterior because positive silhouette

sign with cardiac edge. On the lateral view the opacity fills the retro sternal clear space.

Thymoma

Man, fever and cough for few monthes . Weight loss and

recent severe hemoptisy

Cavity in right retractile upper lobe, associated with right latero hilar

cavity, right inferior lobe infiltrate.

Controlateral cavity in axillar area:

TB cavities, AFB ++ in sputum

Woman, cough but no fever, no worsening condition.

Diagnosis by radiologist and clinician: Right inferior lobe

pneumonia… Do you agree?

Breast prosthesis superposition!

(past history of breast cancer) / Do not make

radiological diagnosis without clinical context

Woman, nurse, small cough .

CXR considered as normal by radiologist….

What do you think?

This CXR is not normal: see small infiltrate of

the right upper lobe and, may be small cavity

in the middle of the right lung

Same patient , 10 monthes after: infiltrate of the upper right lobe with

cavern in the middle lobe.AFB +++. This nurse has not been detected in

time and had possibly contaminated a lot of patients…

Woman , 26 years old, left thoracic pain with fever and chills.on productive cough.

Quick onset of the symptoms. No past history of lung disease.

Case N°11

Chest X ray: technically perfect. Left alvolar opacity which erase cardiac silhouette

on the left inferior arch, positive silhouette sign: the opacity is anterior ,in the

inferior part of the superior lobe (lingula segment). Clinical and radiological signs

strongly suggests acute infectious pneumonia. Quick improvment with 3 g/ day

of amoxicillin…

Case N°12

Cough and hemoptisy. AFB neg. Smoking past history

Cavited bronchial cancer.. Thick and irregular wall. TB is possible but improbable because no bacilli in sputum,

despite cavity in the opacity , and no associated nodules in the periphery of the mass

Man, 60 y , past history of TB treatment. Severe and repeted hemoptisy for many monthes.

Case N°12

Probable bulky aspergilloma in the left upper lobe, developped in

tb sequela cavity.

Case N°12

Chapter 11

Chronic productive cough and repeted infections for years

Repeted smear negative

Case 1

Left inferior lobe bronchectasis

June 2010, 25 years old .Nurse. As

part of the recrutment examination:

CXR considered as normal…

The radiologist has missed a small

tb infiltrate in the right upper lobe…

Case 2

3 years later: Productive cough. Smear ++++ for AFB

TB cavity of the right upper lobe: very high risk of

contamination in the houseold and also in the workplace

Case 2

Morning and chronic productive

cough . Smear negative

Case 3

Bilateral inferior lobe bronchiectasis

Case 3

Man 56 years old,

asthenia cough and

weight loss.Smear - .

Past history of

smoking .

Upper right bulky mass, with no cavitation (false picture of cavity due to

rib superposition). TB is very improbable: no cavity and no associated

nodules or infiltrate. Bronchial cancer.

Case 4

Scan view of the previous case.

Confirmation of no cavity in the upper right

lobe mass

Case 4

Case 5

Fever , weight loss and cough smear (-)

Cambodian National TB control program

Right superior lobe infiltrate with right latero tracheal adenopathies:

Smear negative Culture Positive: TB

Case 5

The association of nodular and linear images suggests

in this context a carcinomatous lymphangitis (renal origin)

Man , 42 years old, severe dyspnea and worsening condition.

Past history of nephrectomy for renal cancer

Case 6

Case 6

The association of nodular and linear and reticular pictures is

much more visible on CT scan

Case N°7

Fever, dyspnea and headaches for 5 days

Left superior lobe pneumonia.

J1: beginning of treatment with amoxicillin.

J5: no improvment , Urine analysis positive for legionnella antigen.

Modification of treatment with introduction of iv erythromicin

Case N°7

J12: signifianrt improvment with apyrexy

and no more dyspnea. Residual asthenia

Case N°7

Man, 59 years old, hemoptisy with AFB negative in sputum. Good health condition.

Past history of pulmonary tuberculosis, with a nine monthes treatment 4 years ago..

Case N°8

Case N°8

Same patient 2 years later (2006): possible « nodule » in the late

retroclavicular area (always compar right and left for analysis of the

retroclavicular area.). New isolated hemoptisy. Smear negative

Case N°8

Same patient, November 2007. Hemoptisy with spontaneous

improvment. Smear negative. Always good health condition.

Notice that the retroclavicular picture seems bigger than 2006

WHAT IS YOUR DIAGNOSIS?

Case N°8

Same patient, june 2009: very severe hemoptisy, life threatening situation.

Improvment with IV glypressine treatment before emergency thoracic surgery

surgery ( left superior lobectomy.)

Notice on the chest X ray before surgery the enlargment of the retroclavicular

opacity, inside the TB sequella cavity. Clinical and radiological evolution is highly

suggesting of aspergilloma.

Case N°8

Same patient:Typical aspect of

aspergilloma on scannographic view

2006 2007

2009

Case N°8

Men , 45 years old. Asthenia et weight loss. Nocturnal sweat and chronic

cough. Smear negative

Case N° 9

CXR: middle lobe opacity with retraction on the right side and

enlargment of the mediastinum and right hilus: probable adenopathies.

In this clinical context TB must be suspected.

Case N° 9

Mediastinoscopy: positive for TB lesion. If no

mediastinoscopy possible TB treatment must be

nethertheless instaured on clinical and radiological

argument

Case N° 9

Same patient after Tb treatment (right side): regression

of mediastinum enlargment and middle lobe pneumonia

25/01/2010 11/02/2011

Case N° 9

Before and after

treatment .

Notice the decrease

of volume of the

lymphe nodes

Case N° 9

CXR library for TB Diagnosis.- Cambodian National TB control program

Case N° 10

Cough an thoracic paint for few weeks . Smear negative

CXR library for TB Diagnosis.- Cambodian National TB control program

Case N° 10

Pleural encysted effusion. Possible pleural TB but others

etiologies are possible (non tb infection..) Exploratory

thoracentesis is necessary, if possible after ultrasound

tracking

CXR library for TB Diagnosis.- Cambodian National TB control program

Case N° 11

Young women. Fever , weight loss and non productive cough for 2 monthes.

CXR library for TB Diagnosis.- Cambodian National TB control program

Case N° 11

Well limited opacity which does not erase aortic arch,and push the trachea. Notice

also that the external limit is sharp under the clavicle and blurred over: So, this

opacity is in the anterior mediastinum middle tier. The most probable diagnosis is

thymoma or more probably LYMPHOMA.

Tb adenopathies are less probable

Case N° 12

Man, 6 years old ,heavy smoker. Left thoracic paint ,

cough, asthenia and weight loss. Smear negative

Case N° 12

Notice the retraction and blur of the superior part of the left lung. On the profil view

you see the retracted systematised opacity: lest superior lung atelectasis.

In this clinical context you must suspect a bronchial cancer and, if possible propose

a bronchoscopy for diagnosis confirmation

Chapter 12

CXR library for TB Diagnosis.- Cambodian National TB control programMan , f

Case N° 1

Man, fever and cough . Mild hemoptisy. Smear

negative an culture negative

CXR library for TB Diagnosis.- Cambodian National TB control programMan ,

Case N° 1

Right latero tracheal adenopathy with probable hilar mass. TB is

possible. But bronchial cancer with mediastinum associated

adenopathies is more probable. Bronchoscopy and, if possible, TDM

is required for diagnosis confirmation.

CXR library for TB Diagnosis.- Cambodian National TB control program

Case N° 2

Woman, acute dyspnea and non productive cough, worsening condition

CXR library for TB Diagnosis.- Cambodian National TB control program

Case N° 2

Diffuse , alveolar and interstitial pneumonia. Bacterial or viral pneumonia is

possible. In case of HIV context, the most likely diagnosis is pneumocystosis

CXR library for TB Diagnosis.- Cambodian National TB control program

Case N° 3

Chronic productive cough with repeted bonchial

infections

CXR library for TB Diagnosis.- Cambodian National TB control program

Case N° 3

Multiple cavities in the retro cardiac area. Probable

left inferior lobe bronchiectasis

Cough and left thoracic paint. Smear negative.

TB treatment or not?

Case N° 4

Left pleural effusion with right axillar and bilateral

retro clavicular infiltrates. Mediastinum enlargment (probable

adenopathies) Culture positive : Tuberculosis

Case N° 4

Slight fever and cough. Smear negative

TB treatment or not?

.- Cambodian National TB control program

Case N° 5

Right superior lobe infiltrate. Culture positive

Tuberculosis

.- Cambodian National TB control program

Case N° 5

Case N° 6

Man, 65 years old . Heavy smoker. Worsening condition and

severe left shoulder and dorsal thoracic paint. Smear negative.

TB treatment or not?

Case N° 6

Left superior lobe mass with thoracic wall

exrtension.: Bronchial cancer. Notice the

false picture of cavity which is the

consequency of rib superpositions.

No need of tb treatment..

Case N° 7

Cough fever and weight loss for 3 monthes Smear

negative Do you initiate tb treatment or not?

Case N° 7

Left superior lobar pneumonia (with aeric bronchogram) and right superior lobe

infiltrate. Calcified left hilus adenopathies: The association of these different pictures

strongly suggests TB.

gene expert or Culture should be positive if available

In this case TB treatment is mandatory because of clinical and radiological context

.-Cambodian National TB control program

Case N° 8

Man, chronic dyspnea and chronic productive cough with

frequent bronchial infections. Past history of TB in house hold

and TB treatment in childhood.

Do you think tb retreatment is necessary or not?

.-Cambodian National TB control program

Case N° 8

Diffuse bronchiectasis of the left lung, which is restracted and

distroyed. Typical of TB important sequella. No need of

retreatment (smear and culture negative)

Case N°9

Men ,57 years old, weight loss and hemoptisy. Past history of smoking.

Smear negative

Case N°9

Overlap of the left hilus by a mass . (notice that vessels are visible through

the mass. It is an anterior overlap , because the mass is in contact with heart:

(positive silhouette sign). Notice that left lung is slightly retracted with

attraction of the trachea and ascension of the left diaphragm

Final diagnosis is bronchial cancer with partial left superior lobe atelectasis

Case N°10

Woman78 years old, past history of hypertension, increasing

dyspnea, with cough . Smear negative

Case N°10

Notice cardiac enlargment, blur and enlargment of the hili with

vascular convergence : probable cardiac failure on the begining.

Spontaneous evolution: severe dyspnea with hypoxemia,

bilateral crepitant rales: CXR bilateral alveolar patern

acute pulmonary oedema

Case N°11

Woman, 37 years old.chronic cough with ,sometimes hemoptoïc sputum.

Repeted bronchial infections . Repeted smear negative for AFB

Case N°11

Right inferior lobe bronchiectasis. Look at the magnified view in

the following slide

Typical rail pictures highly suggestive of cylindric bronchiectasis

Case N°12

Woman, 54 years old, bad clinical condition , weight loss

, cough . Sputum negative for AFB.

Case N°12

Mediastinum elargment highly indicative of adenopathies

, with macronodules , left side predominant, and

probable partial right inferior lobe atelectasis. This

radiological features highly suggest neoplasic process

with pulmonary and node dissemination. Primitive tumor

could be pulmonary, or extra pulmonary.